SAVE THE DATE

NAPCRG 2013

8 Sessions

P025 Assessment of Community Resource Needs Among Patients in an Urban Underserved Primary Care Office

Eugene Bailey, MD; Sarah Beth Evans; Christopher P. Morley, PhD

Context: The Institute of Medicine recommends the integration of primary care with public health and community resources. A critical step is involving the community in defining its own needs. By identifying community resource needs, primary care offices can improve coordination and collaboration with existing community organizations. Objective: The main objective is to identify the community resource needs among patients at an urban primary care office. A key secondary objective is to determine staff perceptions of patient community resource needs at the same urban primary care office. Human Subjects Review: Exempt from IRB review by the SUNY Upstate IRB Design: The survey is a descriptive, exploratory needs assessment utilizing both patient and staff surveys. Both surveys include questions concerning community resources for 4 categories: (1) Specific Medical Conditions (e.g. asthma, diabetes, mental illness); (2) General/Social Needs (e.g. food assistance, child care, jobs training); (3) Health Needs (e.g. health insurance, medical transportation, nutrition education); and (4) Specific Population Groups (e.g. refugees, pregnant women, persons with disabilities). Setting: An urban, nonprofit primary care office with a large percentage of Medicaid, Medicare, and uninsured patients Patients or Other Participants: Both the patient and staff surveys are voluntary and anonymous. The patient surveys are offered to all patients above age 18 when checking into the office. The staff surveys are offered to all staff members above age 18 through staff mailboxes. Intervention/Instrument: Patient and Staff surveys. Outcome Measures: Primary outcome measures are self-identified patient community resource needs. The secondary outcome measure is staff perceptions of patient community resource needs. Inferential analyses will be conducted if appropriate. Level of generalizability of results will be assessed. Anticipated Results: A descriptive analysis of community resource needs from both the patient and staff perspective. Conclusions: The results will be utilized to enhance coordination of primary care with community resources.

P145 Exploring the Relationship Between Exposure to Greenspace, Human Stress and Prevalence of Disease

Context: Many studies have found an inverse relationship between the amount of greenspace (GS) in a neighborhood and both the background stress level of residents and various measures of mortality and morbidity. However, while availability of nearby GS has been considered, measuring actual exposure to GS on stress and disease in existing populations outside of an experimental setting has not been done. Objective: To describe the relationship between exposure to GS and human stress and chronic disease in Baltimore, Maryland. Design: Survey distributed in a stratified random sample to assess intensity, duration, and frequency of exposure to GS along with levels of stress and chronic disease. Setting: City of Baltimore, MD Participants: Adult (age 18 years or greater) residents of Baltimore, MD. Instrument: Survey incorporating questions about GS exposure with the Perceived Stress Scale (PSS), questions about general medical history, physical activity, and demographic information. Main and Secondary Outcome Measures: The existence and strength of any associations between GS exposure and 1) stress as measured on the PSS, and 2) presence of chronic illness will be determined via multivariate linear and logistic regression analysis, which will control for demographic characteristics and physical activity level. Results & Conclusions: The results of this study may have important implications for primary care providers in accounting for environmental variables in the care of their patients, as well as urban planners and public health officials interested in building healthy living environments for urban residents.

P164 Utilizing a Group Visit Model to Deliver “Four Pillars of Wellness” Integrative Care for Adult Patients With Diabetes

Kaushal Nanavati, MD; Morgan Pratte; Christopher P. Morley, PhD

Context: An integrative medicine approach to chronic disease management, entitled “the Four Pillars of Wellness” (FPW) is under development. FPW consists of counseling, guidance and goal-setting in the domains of Nutrition, Physical Exercise, Stress Management, and Spiritual Wellness. Objective: To assess the impact of FPW, delivered via group visits, on Diabetes (Type 1 & 2) in adults. Setting: Academic primary care practice, with potential expansion to PBRN partners. Participants: Adult patients with either Type-1 or Type-2 diabetes (N=60), with 15 patients identified by each of six providers within the practice. Participants will be randomly assigned to FPW group visits, standard group visits, or usual individual care. Instruments: SF-36 quality of life, Cohen Perceived Stress Scale, PHQ-9, metabolic indicators (glucose, BP, lipids, BMI), Diabetes Knowledge Scales, patient journal. Primary and Secondary Outcome Measures: Effect size of FPW Group Visit vs. standard group visit vs. usual individual care for Glucose control (Hb A1C, blood glucose), changes in BMI, lipid profile, BP; controlling for quality of life (SF-36 score), underlying depression (PDQ-9), and perceived stress (Cohen scale), program adherence, and subject demographic characteristics. Change in diabetes knowledge and in overall program adherence. Anticipated Results & Conclusions: We will report effect size of each treatment modality, and will also interpret the results within the context of the implementation of the FPW-Group Visit modality

Context: The integration of Public Health (PH) competency training into medical education has been urged by the U.S. Institute of Medicine (IOM). However, PH competencies are numerous, and there is no consensus over which competencies are most important for adoption by current trainees. The IOM has also called for further integration of public health and primary care. Primary care education may be an appropriate context to introduce PH skills training. Objective: To conduct a concept mapping exercise that will initiate a consensus-building dialogue among stakeholders regarding the most crucial PH skills to incorporate and highlight in undergraduate and post-graduate medical curricula. Setting: National data collection effort, by invitation. Participants: Family Medicine Educators, identified through the Society of Teachers of Family Medicine Group on Public Health Education. Additional informants from other facets of medical education, as well as from PH education and practice, will be identified via snowball sampling. Instruments: The Concept System™ Global Max (http://www.conceptsystems.com) concept mapping data collection and analysis software. Primary and Secondary Outcome Measures: Each participant suggests up to 20 statements that complete the phrase, “A key Public Health competency for physicians-in-training to learn is...”. The statements are then sorted into conceptual groups by a subgroup of the participants, and rated along dimensions of feasibility and importance. CS Global Max software converts participants’ sorted ideas into a two-dimensional point map. The analyses include a multi-dimensional scaling analysis of the sorted ideas, and hierarchical cluster analysis of the resulting coordinates. Anticipated Results & Conclusions: The resulting maps show individual statements as x,y coordinates on a graph, with the most related ideas located proximally and the most disparate factors located furthest apart. Groupings of related ideas, as well as the relative importance of these ideas, can thus be compared visually.

ET33 The Extent and Methods of Public Health Instruction in Family Medicine Undergraduate and Graduate Medical Education

Context: The IOM recommends integrating public health (PH) instruction into medical education curricula. Family medicine educators are well positioned to lead PH integration. The status of PH instruction nationally for physicians-in-training is not well defined. Objective: Determine extent and methods of PH instruction in family medicine residencies (FMR) and undergraduate medical education (UME). Design: National surveys. Setting: US FMR and allopathic medical schools. Patients or other participants: All identified FMR directors and UME family medicine clerkship directors were invited to complete a Council of Academic Family Medicine Education Research Alliance (CERA) survey without exclusion criteria. Instrument: CERA program director and clerkship director surveys. Outcome measures: PH instruction hours, delivery methods by content area, and relationships between instructional hours and site characteristics. Results: 156/431 (36.2%) program directors and 48/134 (35.8%) clerkship directors completed at least one PH item on their survey. FMR and UME programs devote a mean 228 and 37 hours respectively to PH instruction throughout their curricula. FMR instructional hours for most PH content areas are didactic (range: 57%-69% didactic), except for Behavioral Health (37% didactic), Communication (37% didactic), and Community-Based Participatory Research (42% didactic). Female respondents report more hours (327.0) of PH instruction than male respondents (189.4) (p=0.023). Program type and residency city size are not associated with PH instructional hours. Nearly half (49.2%) of UME PH instructional hours are experiential, concentrated in Communication (mean 9.86 ± 16.42 hours), Cultural Competence (mean 7.27 ± 16.22 hours), and Behavioral Sciences (mean 5.83 ± 6.83 hours). Less time is devoted to other PH content areas. Responding clerkship directors at public medical schools (versus private) report more PH instruction. Conclusions: There is variability in the extent and methods of FMR and UME PH instruction. Future research should qualitatively explore instructional methods and identify best practices in PH instruction and integration.

ET34 Intent to Practice in a Rural Location: A Qualitative Study of Medical Students Engaged in Rural Training

Christopher Morley, PhD; Carrie A. Roseamelia, MA

Context: Medical school applicants from rural areas and/or who are interested in primary care are more likely to go into rural practice, and rural training tracks (RTTs) often focus recruitment efforts on such applicants. However, rates of eventual rural practice by RTT graduates are incomplete, ranging from 26% to 60%. Objective: To identify and describe factors influencing desire to practice rurally among students in a fairly typical RTT. Design: An exploratory, qualitative phenomenological study using focus group and individual interviews. Setting: A rural training track at an allopathic U.S. medical school. Participants: 1st-2nd year medical students (MS1-2s) enrolled in a didactic rural health elective (focus group sessions); 3rd-4th year students (MS3-4s) engaged in a longitudinal alternative rural clinical training track (individual interviews). Participation of eligible students ranged from 29%-50% (9/30 MS1s & 7/24 MS2s participated in focus groups; 5/13 MS3s & 2/4 MS4s participated in individual interviews). Instrument: Semi-structured focus group and interview guides; demographic questionnaire. Outcome Measures: Intent to practice in a rural community; influencing factors on rural practice and specialty choice. Results: Students were drawn to the RTT for focused training in a rural setting. Most students described a “rural identity” (small town family roots, predilections for rural environment, outdoor activities). Most MS1-2s favored family medicine (63%) or pediatrics (13%). MS3-4s’ specialty preferences were more varied. Roughly 1/3 of MS1-2s expected to practice rurally, though many were non-committal. Only two MS3-4s were fully committed to rural practice. Most participants ruled out practicing in an urban setting. Conclusions: Interest in rural training does not necessarily translate to students’ intentions to practice in rural communities. Self-selection into an RTT may be based as much upon “rural identity,” and aversion to urban practice, as upon intention to practice rurally. Assumptions regarding what influences eventual rural practice require further research.

Context: Medical students are often asked which specialty preference, and faculty routinely offer feedback on this complex and important decision. The influence of faculty on career choice is not well established, and data regarding this aspect of the hidden curriculum are needed to increase knowledge to attract and retain student interest in primary care. Objective: To estimate incidence, effects, and balance of positive and negative feedback on primary care as a career choice; secondarily, to determine efficacy of texting as a data collection method for medical students. Design: Multicenter observational prospective study, incorporating data collection via surveys and two 30-day periods of text messaging. Setting: Three U.S. medical schools. Patients or Other Participants: Year 1-3 medical students at participating universities. Outcome Measures: Positive-to-negative faculty comment ratio; student interest in primary care; association between number of comments heard, positive-negative ratio, and overall student interest in primary care; types of comments heard; participant reaction to texting as a data collection method. Preliminary Results: With 5 of 6 data collections completed, 138 medical students participated, divided roughly evenly between year and school. Positive comments (total=853) outnumbered negative comments (total=612), with a ratio of 1.39 positive comments for every negative. Interest in primary care resembled national residency match rates, with 19.2% of students indicating intent to enter primary care, and 20% indicating they probably would. Texting as a data collection method was overwhelmingly endorsed with 90% approving. Conclusions: Attracting and retaining interest in primary care is essential in medical education today. Aspects of the hidden curriculum have been described as important in shaping career decisions of medical students, and feedback from faculty has been named as an area in need of further work. This study aims to contribute novel data to increase understanding of faculty influences on decisions to choose a primary care specialty.

OT31 Oral Health Outcomes, Oral Health Literacy, and Other Barriers to Care at a Community Health Care Center

Context: Low literacy is a suspected factor in poor oral health (OH) outcomes. Objective: To investigate the association between OH literacy levels, outcomes, and barriers to care, and to assess preferred means of receiving OH information. Setting: Low-income community-based dental clinic operated by a public medical university in the northeastern United States. Participants: Patients visiting the dental clinic during a 10-week period (N=141). Instruments: Participants were asked at time of visit to complete a sociodemographic survey, a short-form Oral Health Impact Profile Index (OHIP-14, a measure of oral health-related quality of life), and the REALD-30 (a word recognition literacy test). The treating clinician also completed a short form assessing clinical severity. Outcome Measures: OHIP scores (Severity, Prevalence, Extent); Clinical Severity score rated by clinician (1-5); Proportion reporting a preference for learning materials that could be seen, verbally delivered, watched (e.g. video), read, or worked on by the patient. Patient characteristics and barriers were assessed as predictors of clinical outcomes and of preferences for teaching mechanism via linear and logistic regression techniques. General descriptive outcomes were reported, as well. Results: REALD-30 score had a significant inverse impact on both OHIP Severity (ß= -.697, p=.043) and Extent (ß= -.197, p= .018). “I didn’t have enough money to pay for the visit” was also nearly significant in each case. OHIP Prevalence was predicted by those reporting “other” written-in barriers to care (O.R.= 10.3, p= .028). REALD-30 score was also associated with clinician-rated severity (ß= -.055, p=.044). Patients overwhelmingly preferred verbally delivered OH information, with some variation by race. Conclusions: Literacy level appears to play a robust role in OH outcomes. Patients in this sample preferred verbally-delivered health information in most cases, with little effect of literacy on preference. Therefore, patient education efforts should focus upon verbal modes of delivery and patient-clinician interaction training.